how to make it clear when call doctor

canchaser, BSN, RN · Dec 28, 2012

The patient had " uncontrolled" Afib when the HR was in 130's. even though he was no new to Afib. I don't know what type of facility his is. But there is such a thing as to failure to rescue, I know it's hard to wake them up but do it or at least run it by a coworker to see what they would do. But be ready to stand by YOUR decision, ultimately it is your decision in the end. I understand working nights makes it harder to place the call. Glad the outcome was a good one. The article below is on failure to rescue. While its old, it's still a nice article and to see the thought process of rapid response teams evolution. Nursing Center - Journal Article

Mully · Dec 28, 2012

You definitely didn't need to call the doctor after everything was resolved. That's why he wondered what you wanted him to do, because there was nothing left to do. An important thing I think about with A-fib is this; is it a sustained HR of 130 or did it just hit 130 and go back down? Sustained would be something more serious, however it still might not be something to call the MD about considering that the pt had done this before and was asymptomatic. The thing is, if you didn't call at 0300, there was no need to call at 0530. And p.s., unless there were parameters on the metoprolol, I probably would have given it the first time since bringing the HR down will usually increase the BP as it pumps more efficiently. Next time, ask your colleagues.

meandragonbrett · Dec 28, 2012

Was this a CV Surgery patient? Had he always been in AFib since his original change? Did he ever convert to sinus? What is he in the hospital/unit? These are all questions to ask yourself.

neurontin · Dec 28, 2012

I appreciate your input, Mully.

I asked the charge nurse whether I needed to call and what to say. He said I needed to call the doc at the end of the shift (0700), and let him know what happened. As a new nurse on the floor, even though I was not sure what the doc could do, I thought it probably won't hurt to call him. But I was wrong. the doc was unsatisfied with my call and complained it to the charge nurse (not sure whether he complained it to the manager or not).

What I learned from this lesson (please correct me if I am wrong)

1. when I am not 100% sure, do not do it.

2. do not do exactly what the colleagues say; they can make a suggestion. However, i am the one who take full responsibility. Even though the charge nurse told me what to say, he won't tell the doc, 'I told her to say something like that.'

neurontin · Dec 28, 2012

thank you, meandragonbrett.

those are good questions. But I am not quite sure the difference between the afib on a CV surgery pt and the afib on a non-CV surgery pt?

and why I need to ask myself, 'what is he in the hospital/unit?'

Thank you again for the input.

neurontin · Dec 28, 2012

I never thought about that. Thank you very much for telling me that, canchaser.

I really appreciate it.

Esme12, ASN, BSN, RN · Dec 28, 2012

the pt i had last night had a. fib, HR went to 130; due to he had had a.fib two days ago so that i did not call doctor at 0300 am. plus, pt was asymptomatic.
when i called the doctor later, i tried to make myself clear by saying, "he started to have a.fib at 0300 am, asymptomatic; i held metoprolol because his SBP was less than 90 last night. when his SBP increased to 94, i gave him the med at 0530. right now he is still a.fib. HR 80's."
the doc was not satisfied with what i was saying. he asked me, "why didn't call me at 0300 am (he forgot that this was not new to the pt)? is there any critical thing (to call me)? what do you want me to do?" to be honest, except for letting him know what was going on the pt, i do not know why i called him.
call him or not call him?
any suggestion on how to do if you were me? I would appreciate any input.

Sometimes it is how you say it and not what you say....I would say Dr. Crabby......

Your patient in 304-2 had uncontrolled AFib last night with a heart rate in the 130's that was self limiting and the patient was asymptomatic.....I called because he is still having episodes of self limiting A Fib....I initially held the metoprolol, @ what ever time, due to the B/P being 90 and outside the parameters....I was able to give the metoprolol @ what ever time when his B/P was in the parameters.

The MD says....fine why didn't you call me at three.....say.....I didn't call you at three because the Afib was self limiting...... but thought you needed to know before I leave this morning and before you make rounds.....do you need/want any labs/lytes/Ca/Mg/enzymes, EKG on this patient? No? Ok...have a nice day...

I asked the charge nurse whether I needed to call and what to say. He said I needed to call the doc at the end of the shift (0700), and let him know what happened. As a new nurse on the floor, even though I was not sure what the doc could do, I thought it probably won't hurt to call him. But I was wrong. the doc was unsatisfied with my call and complained it to the charge nurse (not sure whether he complained it to the manager or not).
What I learned from this lesson (please correct me if I am wrong)
1. when I am not 100% sure, do not do it.
2. do not do exactly what the colleagues say; they can make a suggestion. However, i am the one who take full responsibility. Even though the charge nurse told me what to say, he won't tell the doc, 'I told her to say something like that.'

My vote.....when in doubt call. You can't be sued for calling the MD but you sure can be sued for NOT calling the MD.

I could care less if they are ....unhappy..... with my phone calls. That is their job to tell me what I have to say is not important. You need to develop a bit of a thick skin. Call to protect your behind. I would rather be asked why I called than why I didn't call. They don't like it? Whatever....I need to do what is right for me so I can go home and sleep well. I wouldn't say to the MD...the charge nurse told me to...but I would have a talk with your boss about a lack of support from your charge.

Their personal pet peeves (the MD's) mean nothing to me.

MunoRN, RN · Dec 28, 2012

I don't know why CV surgeons insist on being so cryptic with their preferences around a-fib, but they do as an almost absolute rule. A-fib is extremely common in post OHS patients, particularly post AVR patients due to inflammation in the conduction pathways. Yet even though a bout of A-fib should almost be expected, us night shift Nurses always seem to get stuck trying to read the mind of a perpetually fickle CV team when the subject inevitably comes up.

I've had surgeon's tell me that they don't care the patient is in A-fib with a rate of 140, and after I called they couldn't get back to sleep and are now canceling their case for today. I've also had surgeons tell me they wish I had called on a patient who went into A-fib for the 5th time surgery with a rate in the 80's because they were planning on starting an amio drip the next time they went into A-fib. That's an excellent teaching opportunity for you (as in an opportunity to educate the surgeon). Advise them that if that was their plan, they really should have made that known. They can either write an order that says to notify MD for any recurrence of A-fib, or sustained A-fib, etc., or even better, just write an order that says "Amio gtt A-fib protocol for sustained A-fib >10 minutes", etc. I don't think it's inappropriate to communicate to them, politely and professionally, that they failed to communicate effectively and you're more than willing to help them improve on that.

meandragonbrett · Dec 29, 2012

To the OP...you can also read the progress note to see if anything was mentioned such as "non-sustained AFib overnight. If Afib resumes will consider diltiazem or amiodarone." That can sometimes clue you in as to what the team's plan is.

sammiejane33 · Dec 29, 2012

I am a nursing student and learned alot from the original post and this response. I would feel exactly how you feel neurontin. and Esme12 i found your reply very helpful and similar to what one of my insturctors would say. thanks to both of you!

Bec7074 · Dec 31, 2012

The pt may have been a symptomatic at a rate of 130 only temporarily. In afib > 120, the heart loses its "atrial kick" (the small portion of blood ejected from the atria to the ventricles) and thus, cardiac output decreases. I've seen it take a while for pts to become symptomatic (SOB, restless). If it was me, I would have called because of the rate. Live and learn :)